Provider Demographics
NPI:1699320119
Name:OLULOTO, GRACE
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:OLULOTO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 N GREENWOOD AVE STE 302
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74120-1446
Mailing Address - Country:US
Mailing Address - Phone:918-599-7277
Mailing Address - Fax:
Practice Address - Street 1:2740 E 41ST ST N
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74110-1432
Practice Address - Country:US
Practice Address - Phone:865-221-5489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-02
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health